1063700615 NPI number — MRS. JACQUELINE JACKSON

Table of content: MRS. JACQUELINE JACKSON (NPI 1063700615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063700615 NPI number — MRS. JACQUELINE JACKSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
JACQUELINE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063700615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1070 OLD NATIONAL PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15333-2114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-632-6801
Provider Business Mailing Address Fax Number:
724-632-6312

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 W GEORGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMICHAELS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15320-1325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-966-5081
Provider Business Practice Location Address Fax Number:
724-966-2002
Provider Enumeration Date:
07/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1007288440093 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 328834A764918 . This is a "VALUE BEHAVIORAL HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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